What is the recommended management for a patient with severe aortic stenosis and reduced ejection fraction?

Management of Severe Aortic Stenosis with Reduced Ejection Fraction

For a patient with severe aortic stenosis and reduced ejection fraction, aortic valve replacement (either TAVR or SAVR) is appropriate regardless of surgical risk, and medical management alone is rarely appropriate. 1, 2

Immediate Decision: Intervention is Mandatory

Valve replacement must be performed—the only question is which type of valve and which approach. 1, 2

• Reduced ejection fraction (<50%) carries a Class I recommendation for intervention regardless of surgical risk 1, 2
• Medical management receives an appropriateness score of only 1-2 (rarely appropriate) in this clinical scenario 1, 2
• The presence of reduced LVEF eliminates any need for stress testing to inform decision-making 1, 2

Choosing Between TAVR and SAVR: Age is the Primary Determinant

Since the patient's age is uncertain, this becomes the critical factor to clarify:

If Patient is Under 65 Years Old:

Surgical aortic valve replacement (SAVR) is strongly preferred 2

• SAVR receives an appropriateness score of 9 for patients in their 60s with low surgical risk 2
• Younger patients benefit from valve durability and the option of mechanical valves for longer life expectancy 2
• TAVR has never been systematically investigated in young low-risk patients, and long-term data remain lacking 3

If Patient is 65-75 Years Old:

SAVR is generally preferred, though both SAVR and TAVR are acceptable depending on surgical risk 2

• Calculate the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score 2
• If STS-PROM ≤8%: prefer SAVR 2
• If STS-PROM >8%: prefer TAVR 2

If Patient is Over 75 Years Old:

TAVR becomes the preferred option for most patients 1

Surgical Risk Assessment Modifies the Approach

Calculate the STS-PROM score to determine surgical risk category: 2

• High or intermediate surgical risk: Both TAVR and SAVR are appropriate (appropriateness score of 8) 1, 2
• Low surgical risk: SAVR is strongly preferred (appropriateness score of 9) unless specific contraindications exist 1, 2

Factors That Favor TAVR Despite Lower Surgical Risk:

• Frailty 2
• Porcelain aorta 2
• Hostile chest 2
• Prior cardiac surgery 2
• Significant comorbidities 2

Factors That Favor SAVR:

• Younger age (<65 years) where mechanical valve may be considered 2
• Longer life expectancy requiring valve durability 2
• Potential need for future reintervention 2

Special Considerations for Low-Flow, Low-Gradient Scenarios

If the patient has low-flow, low-gradient aortic stenosis with reduced LVEF, perform dobutamine stress echocardiography to distinguish true-severe from pseudo-severe AS 1, 2, 4

• If flow reserve is present on dobutamine and confirms truly severe AS: AVR is appropriate regardless of surgical risk (appropriateness score of 8-9) 1, 2
• If no flow reserve but the valve is heavily calcified on echo/CT suggesting truly severe AS: AVR remains appropriate (appropriateness score of 7) with high or intermediate surgical risk 1, 2
• If minimal calcification on echo/CT with no flow reserve: medical management may be appropriate (appropriateness score of 7 for no intervention) 1

Expected Outcomes with Reduced Ejection Fraction

TAVR may provide superior LVEF recovery compared to SAVR in patients with depressed LV systolic function 5

• In one comparative study, 58% of TAVR patients achieved normalization of LVEF (>50%) at 1-year follow-up versus only 20% in the SAVR group 5
• TAVR patients demonstrated better recovery of LVEF (ΔLVEF 14±15% versus 7±11%) despite being older with more comorbidities 5
• Historical data from SAVR shows dramatic improvement in LV ejection fraction from 0.34 to 0.63 post-operatively 6

Mandatory Requirements Before Proceeding

All decisions regarding valve replacement must involve a multidisciplinary heart team assessment 2, 4

• TAVR should only be performed in hospitals with cardiac surgery on-site 2
• Life expectancy must exceed 1 year for TAVR to be appropriate 2
• Evaluate for untreated coronary artery disease requiring revascularization 2

Critical Pitfalls to Avoid

Do not delay intervention with medical management alone—this is rarely appropriate and associated with poor prognosis 1, 2, 7

• Patients with severe AS and reduced LVEF have poor prognosis with conservative therapy 5
• The encouraging long-term survival and marked improvement in LV function indicate that all patients with severe AS and clinical heart failure should be offered valve replacement 6

Relative contraindications to consider:

• LVEF <20% (though intervention may still be appropriate with appropriateness score of 7) 1, 2
• Bicuspid valve (TAVR not licensed for bicuspid valves in many regions) 8